SYDNEY Seaplanes will take to the skies midweek, two weeks after six people died in a horrific crash aboard one of its planes, with two pilots recruited to man each turbine-powered Cessna C-208 Caravan flight.

The company was poised to resume operations today from Rose Bay but adverse weather conditions has meant the first flight of the year has now been pencilled in for Wednesday.

Bosses of the scenic flights firm suspended operations following the New Year’s Eve crash that killed experienced pilot Gareth Morgan, 44, and five passengers, on board the de Havilland Beaver DHC-2 aircraft.

Pilot Gareth Morgan died in the accident.Its remaining Beaver aircraft will not operate until findings of a preliminary report into the Hawkesbury River crash are made public later this month — instead the company’s two Cessna C-208 Caravan aircraft will each be flown by two pilots in a bid to increase passenger confidence.

A statement released today from Seaplane Pilots Association Australia’s vice president Kevin Bowe read: “Given its long and successful flying history, Sydney Seaplanes is confident there are no systemic failings in the de Havilland Beaver DHC-2 aircraft, the type that crashed on New Year’s Eve.

“However, the company will not be flying its remaining de Havilland Beaver DHC-2 aircraft in advance of the release of the Australian Transport Safety Bureau’s Preliminary Factual Report.

Flights will now have two pilots on-board. Picture: Lenn Bayliss“Flight services will commence with the company’s Cessna C-208 Caravan aircraft, both turbine powered 2008 models.

“These aircraft are serviced and maintained by Australia’s Cessna certified maintenance facility, Hawker Pacific at Bankstown Airport, who ensure the aircraft’s airworthiness and high standards of maintenance.”

British millionaire Richard Cousins, 58, died alongside his partner Emma Bowden, 48, his two sons, Will and Edward, aged 25 and 23 respectively, and Ms Bowden’s daughter, Heather, 11.

Mr Morgan’s funeral was held in Waverley last week, with his devastated mother and father in attendance after they arrived from Canada.

Emma and Heather Bowden.The Australian Transport Safety Bureau (ATSB) is leading the investigation into the tragedy, which happened shortly after the de Havilland DHC-2 Beaver they were travelling in took off from Cottage Point.

The ATSB is interviewing witnesses, examining recorded data from the on-board electronics and air traffic control logs as well as poring over the plane’s maintenance records.

The wreckage of the doomed seaplane was recovered from 13m of water in the days after the tragedy.

The preliminary factual report into the crash is expected to be released by early next month.

Sydney Seaplanes managing director Aaron Shaw said getting back to the air was “necessary” for business.

“It’s also what our late colleague Gareth Morgan, a passionate seaplane pilot for all of his adult life, would have wanted,” he said.

Over the next 12 months the ATSB will compile a detailed report to pinpoint exactly what caused the fatal crash and use this information to try to prevent future tragedies.

The aircraft at the centre of the crash, which the Duchess of Cambridge’s sister Pippa and her husband James Matthews flew in when they were in Sydney last year, had been rebuilt more than 20 years ago after it was destroyed in another fatal crash.

It is estimated Sydney Seaplanes, which turns over $8 million a year, has lost about $21,000 in revenue for each day it has been grounded.The company usually flies between 280 and 300 passengers a day during peak periods.

Also on the Australian AAI front yesterday the ATSB released a statistical report on AAI occurrences between the years 2007 to 2016:

Quote:Aviation Occurrence Statistics 2007 to 2016

The purpose of this report

Each year, thousands of safety occurrences involving Australian and foreign-registered aircraft are reported to the Australian Transport Safety Bureau (ATSB) by individuals and organisations in Australia’s aviation industry and by members of the general public.
This report is part of a series that aims to provide information to the aviation industry, manufacturers and policy makers, as well as to the travelling and general public, about these aviation safety occurrences. In particular, what can be learned to improve transport safety in the aviation sector.

The study uses information over the ten-year period from 2007–2016 to provide an insight into the current and possible future trends in aviation safety, and takes a detailed look at the accidents and incidents in 2016 for each type of aircraft operation.

What the ATSB found

The majority of air transport operations in Australia each year proceed without incident.

In 2016, nearly 230 aircraft were involved in accidents in Australia, with another 291 aircraft involved in a serious incident (an incident with a high probability of an accident).

There were 21 fatalities in the aviation sector in 2016, which was fewer than any previous year recorded by the ATSB. There were no fatalities in either high or low capacity regular public transport (RPT) operations, which has been the case since 1975 and 2010 respectively.

Collision with terrain was the most common accident or serious incident for general aviation aircraft, recreational aviation and remotely piloted aircraft in 2016. Aircraft control was the most common cause of an accident or serious incident for air transport operators.

Wildlife strikes, including birdstrikes, were again the most common types of incident involving air transport and general aviation operations, with runway events the most common type of incident for recreational aviation.

The accident and fatal accident rates for general and recreational aviation reflect the higher‑risk operational activity when compared to air transport operations. They also reflect the significant growth in recreational aviation activity over the last ten years and this sector’s increased reporting culture.

General aviation accounts for one‑third of the total hours flown by Australian-registered aircraft and over half of all aircraft movements across Australia.

The total accident rate, per hours flown, indicates general aviation operations are 10 times more likely to have an accident than commercial operations, with recreational aircraft around twice as likely to experience an accident than general aviation.

The fatal accident rate, per hours flown, indicates general aviation operations are around 20 times more likely to experience a fatal accident than commercial air transport, and recreational operations are almost 40 times more likely to experience a fatal accident than air transport.

Recreational gyrocopters experienced the highest fatal accident rate for any aircraft or operation type, whereas recreational balloon operations had the highest total accident rate; almost four times as high as any other aircraft operation type. There were no fatal accidents involving recreational balloons reported during the study period.

Aeroplanes remain the most common aircraft type flown which is reflected in their involved in accidents. In 2016, nine of the 15 fatal accidents involved aeroplanes—three helicopters and two powered weight shift aircraft were also involved in fatal accidents.
In 2016, the increased availability and use of remotely piloted aircraft (RPA) saw them surpass helicopters as the second highest aircraft type for reported accidents; however, there were no collisions with other aircraft, fatalities or serious injuries relating to RPA reported to the ATSB that year. While the consequences of an accident involving an RPA have been low to date, their increased use, and possible interactions with traditional aviation, is an emerging trend in transport safety that will continue to be monitored closely by the ATSB.

Safety message

This report highlights the importance of effective and timely reporting of all aviation safety occurrences, not just for the potential of initiating an investigation, but to allow further study and analysis of aviation transport safety.

While there has been an increase in accident and incident reporting, the limited detail provided for most occurrences, especially by recreational flyers, remains a challenge for the industry and ATSB. This report also highlights the need for improvements in the reporting rates for some areas in general aviation.

By comparing accident and occurrence data across aviation operations types, the ATSB is able to develop a complete picture of the aviation industry to identify emerging trends in aviation transport safety, identify further areas for research and recommend pre-emptive safety actions.

The ATSB has released its annual statistical review of Australian aviation safety occurrences, Australian Aviation Safety Occurrences, 2007 – 2016.

The report brings together information over ten years, from 2007 to 2016, to provide insights into current and possible future trends in aviation safety, and takes a detailed look at the accidents and serious incidents in 2016 for each type of aircraft operation.

ATSB Chief Commissioner Greg Hood said the report provides important information for the aviation industry, manufacturers and policy makers, as well as the travelling and general public, on aviation transport safety.

“By comparing accident and occurrence data across aviation operations types, the ATSB is able to identify emerging trends, further areas for research and take steps to recommend pre-emptive safety actions,” Mr Hood said. “While I am grateful that there were fewer fatalities in the aviation sector in 2016 than in any previous year recorded by the ATSB, any loss of life is a poignant reminder of the importance of our work to better understand the multilayered causes of aviation safety occurrences.

In 2016, nearly 230 aircraft were involved in accidents in Australia, with 291 involved in a serious incident (an incident with a high probability of an accident). Across the different operation types:

commercial air transport operations experienced one fatality from 15 accidents

general aviation experienced 10 fatalities from 119 accidents

recreational aviation had 10 fatalities from 63 accidents.

Nine of the 15 fatal accidents involved aeroplanes. Three helicopters and two powered weight shift aircraft were also involved in fatal accidents. There were no fatalities in either high or low capacity regular public transport (RPT) operations.

The report also provides insights into an emerging trend in transport safety—the increased use of remotely piloted aircraft (RPA). In 2016, RPAs surpassed helicopters as the second highest aircraft type for reported accidents; however, there were no collisions with other aircraft, fatalities or serious injuries relating to RPA reported to the ATSB. While the consequences of an accident involving an RPA have been low to date, their increased use, and possible interactions with traditional aviation, will continue to be monitored closely by the ATSB.

Mr Hood said the report highlights the importance of effective and timely reporting of all aviation safety occurrences. “This is not just for the potential of initiating an investigation, but to allow further study and analysis of aviation transport safety,” Mr Hood said.

HVH:“By comparing accident and occurrence data across aviation operations types, the ATSB is able to identify emerging trends, further areas for research and take steps to recommend pre-emptive safety actions,”

Is that like the ATSB closing safety loops on serious safety issues that having been identified, in some cases nearly 2 decades ago, & despite political and aviation safety bureaucratic rhetoric, are yet to be effectively risk mitigated...

In summary, the Instrument is a step in the right direction but is unfinished business. There are serious concerns about the application or otherwise of the body of fatigue science and research and the preservation or extension of existing provisions already challenged by parts of the industry as unsafe.

CASA has an abysmal record of regulatory oversight of fatigue management, even without the pressure of trying to get some serious traction on the Regulatory Reform programs that have diverted them for the last 17 or so years. Parts of the industry believe that CASA has seriously underestimated the resources required to implement these new rules and that there will be an inevitable trade-off in surveillance activities of flight operations.

If not disallowed now, this legislation will continue with no incentive for improvement unless and until the inherent risk crystallises into an undesirable outcome. That is not a possibility that this Parliament should allow to persist.

(01-16-2018, 11:34 AM)Peetwo Wrote: HVH:“By comparing accident and occurrence data across aviation operations types, the ATSB is able to identify emerging trends, further areas for research and take steps to recommend pre-emptive safety actions,”

Is that like the ATSB closing safety loops on serious safety issues that having been identified, in some cases nearly 2 decades ago, & despite political and aviation safety bureaucratic rhetoric, are yet to be effectively risk mitigated...

In summary, the Instrument is a step in the right direction but is unfinished business. There are serious concerns about the application or otherwise of the body of fatigue science and research and the preservation or extension of existing provisions already challenged by parts of the industry as unsafe.

CASA has an abysmal record of regulatory oversight of fatigue management, even without the pressure of trying to get some serious traction on the Regulatory Reform programs that have diverted them for the last 17 or so years. Parts of the industry believe that CASA has seriously underestimated the resources required to implement these new rules and that there will be an inevitable trade-off in surveillance activities of flight operations.

If not disallowed now, this legislation will continue with no incentive for improvement unless and until the inherent risk crystallises into an undesirable outcome. That is not a possibility that this Parliament should allow to persist.

General aviation is about 20 times more likely to experience a fatal accident than commercial operations.

The Australian12:00AM January 19, 2018

ANNABEL HEPWORTH
Aviation Editor Sydney
@HepworthAnnabel

The nation’s air crash investigator is hoping for better reporting of incidents after new data showed how much more likely accidents are for recreational flyers and ­general aviation than commercial air transport.

Australian Transport Safety Bureau chief commissioner Greg Hood said that better reporting “enables the industry, pilots and the regulator to learn from trends seen in more minor safety occurrences to help avoid more serious accidents”.

An ATSB report released this week shows that, based on hours flown, general aviation operations are 10 times more likely to have an accident than commercial air transport, and recreational aircraft are about twice as likely to experience an accident than general aviation.

On hours flown, general aviation is about 20 times more likely to experience a fatal accident than commercial operations, and fatal accidents among recreat­ional ­flyers are almost 40 times more ­likely than with air transport.

The ATSB notes in the report that while there has been a rise in the reporting of accidents and ­incidents, the “limited” detail for most events, particularly for recreational flyers, “remains a ­challenge for the industry and ATSB”.

The bureau also pointed to “the need for ­improvements” to the ­reporting rates for some areas of general aviation.

In response to inquiries by The Australian, Mr Hood said the ATSB had found that fewer incidents and “non-accidents” had been reported to the body by the general and recreational aviation sectors of the industry.

“For some operation types, such as mustering for example, nearly every occurrence being ­reported is an accident — some 80 per cent of mustering occurrences get reported as accidents. This data suggests that there may be other incidents and serious ­incidents that are not being reported to us,” Mr Hood said.

“When an accident and incident report comes from external parties such as the police, air ­traffic control or other pilots, there is often a lack of detail, namely around what and why it occurred.”

Mr Hood said better reporting directly to the ATSB would allow data to be used to pinpoint risks for certain operations, aircraft and locations. “This enables the industry, ­pilots and the regulator to learn from trends seen in more minor safety occurrences to help avoid more serious accidents.”

However, he said he was pleased with work done by organisations such as the Aerial Appli­cation Association of Australia, Recreational Aviation Australia and the Sport Aircraft Association to actively promote reporting to the body.

Recreational Aviation Australia chairman Michael Monck said there had been concerns among aviators in the past that “if you ever told the regulator something, chances are you will be punished”, but there had been a big push in recent years to ­encourage disclosure.

“That’s something that certainly scared off aviators in the past from reporting. That is changing,” Mr Monck said.

On 19 November 2017, a GIE Avions de Transport Regional ATR 72-212A aircraft, registered VH‑FVZ, was being operated by Virgin Australia as flight VA646 on a scheduled passenger flight from Sydney, New South Wales to Canberra, Australian Capital Territory. On board the aircraft was the captain, first officer, a check captain, two cabin crew and 67 passengers.
The first officer was pilot flying, and the captain was pilot monitoring.[1] The check captain was positioned in the observer seat on the flight deck and was conducting an annual line check of the captain along with a six month line check of the first officer over four flights on the day. The occurrence flight was the last of these flights.

At about 1320 Eastern Daylight-saving Time (EDT),[2] the flight crew were conducting a visual approach to runway 35 at Canberra. The calculated approach speed was 113 kt. At 1320:52, nine seconds prior to touch down, the aircraft approached the runway at a height of about 107 ft, slightly above the desired approach path. The flight crew reported that at about this time, there was turbulence and changing wind conditions. Flight data showed that at this time, speed had increased to 127 kt. In response to the increasing speed, the first officer reduced power to near flight idle.

Over the next five seconds, the descent rate increased significantly and the speed reduced.
During the last 50 ft of descent, the captain twice called for an increase in power and then called for a go-around. The first officer responded by increasing the power at about the same time as the aircraft touched down.

At 1321:01, the aircraft touched down heavily on the main landing gear and rear fuselage. Assessing that the aircraft was under control, the captain immediately called to the first officer to cancel the go-around and then took control of the aircraft. The flight crew completed the landing roll and taxied to the gate without further incident.

After shutting down the engines, the flight crew reviewed the recorded landing data which indicated a hard landing had occurred, requiring maintenance inspections. The captain then made an entry in the aircraft technical log, and subsequent inspections revealed that the aircraft had been substantially damaged. There were no reported injuries.

Aircraft damage

The aircraft sustained impact and abrasion damage to the underside of the rear fuselage and tail skid (Figure 1). Damage to the tail skid indicated that it was fully compressed during the landing. After landing, the main landing gear oleos remained fully compressed, indicating they had lost gas pressure.

At the time of the release of this report, the operator was conducting an engineering examination of the aircraft, in consultation with the aircraft manufacturer, to determine the extent of further damage and the required repair work to be undertaken.

Figure 1: Damage to the tail skid an underside of the rear fuselage
Source: ATSB

Weather and environmental information

Recorded weather observations at Canberra Airport indicated that at the time of the accident, there was scattered cloud at about 7,000 ft above mean sea level,[3] no precipitation, visibility in excess of 10 km, and a moderate north-easterly wind of about 16 kt.

The approach to runway 35 passes over undulating higher ground, which can be a source of mechanical turbulence. The flight crew reported that they regularly experienced turbulence at all stages of approach and landing at Canberra.

Aircraft information

The ATR 72-212A is a twin engine turboprop regional airliner. VH-FVZ was manufactured in 2013 and first registered in Australia in May 2013, and was configured with 68 passenger seats. The maximum landing weight of the aircraft was 22,350 kg. At the time of the landing, the gross weight was about 21,700 kg.

The aircraft’s flight crew operating manual recommended that prior to landing, power should start to be reduced to flight idle at a height of about 20 ft. The manual also advises that during the landing flare, speed will reduce five to ten knots below the approach speed.

Recorded data

The aircraft was fitted with a cockpit voice recorder and a flight data recorder, which recorded the flight data associated with the occurrence (Figure 2).

Figure2: Graphical representation of recorded flight data
The figure shows relevant recorded parameters captured by the flight data recorder. The landing and selected approach speed are annotated.
Source: ATSB

The recorded data indicated that the approach was flown in conditions of light turbulence, and at about 1320:47, excursions of vertical acceleration indicate that the aircraft encountered turbulence. At this time, speed began to increase, and both engines were reduced to near flight idle power. The pitch attitude initially decreased before the nose raised to a near level attitude until the landing flare.

At the time of the touchdown, the descent rate was 928 feet per minute, the speed was 105 kt, and the peak pitch angle was 5.45 degrees. The peak recorded vertical acceleration during the landing was 2.97G.

Continuing investigation

The investigation is continuing and will include further analysis and examination of the:

It’s a rare thing these days to read some old fashioned ‘straight talk’ on the UP, particularly in relation to aircraft operating. But, every now and again, someone who knows what they are about speaks up. Bravo Di Vosh; hear, hear.

"I don't know if you've ever flown a large Turboprop. If you have, you should know that reducing the power levers to "near flight idle" at 107' AGL is going to guarantee you a heavy landing unless you re-apply most or all of that power as soon as your speed gets back to your desired range."

It’s a rare thing these days to read some old fashioned ‘straight talk’ on the UP, particularly in relation to aircraft operating. But, every now and again, someone who knows what they are about speaks up. Bravo Di Vosh; hear, hear.

"I don't know if you've ever flown a large Turboprop. If you have, you should know that reducing the power levers to "near flight idle" at 107' AGL is going to guarantee you a heavy landing unless you re-apply most or all of that power as soon as your speed gets back to your desired range."

I'm just surprised no one was seriously hurt.

Toot - toot.

My turn on UP duty and I must admit to rapidly becoming a fan of Di Vosh as well...

Quote:scifi

I didn't miss it. If every time there was a heavy landing due..

"..turbulence and changing wind conditions.."

..the worlds fleet of airliners would be grounded weekly.

As I've said (more than once) I've flown that approach a few times. There is ALWAYS "turbulence and changing wind conditions" on approach to Canberra, even on a day with light and variable winds. I can guarantee that a 16 knot NE wind will give a crew plenty of work on final, but it's not that unusual.

The METAR winds of the day do not support your theory of a 22 knot wind change, and I would suggest to you that if that kind of wind set was active in Canberra at the time (and it does) there would be NOTAMS for moderate/severe turbulence below 8000', and there would be turbulence and/or undershoot/overshoot shear advices on the ATIS, none of which appeared to be present on the day.

Have you flown a heavy turboprop? Are you aware of what happens to aircraft performance when the power levers are placed "near flight idle"? (God forbid when in the landing configuration)

The report states that the FO reacted to the increased airspeed and reduced the power levers to "near flight idle" approximately 9 seconds before landing and then didn't touch them for over five seconds.

That is a recipe for disaster!

DIVOSH!&..

There's obviously a second theme running here, as evidenced by people who appear to be VARA pilots posting about possible "issues" within their own C&T system.

Fair enough.

I would like to put my P.O.V. re: Cadets vs. experienced pilots in the RHS.

I spent around 25 years in the Army. Mainly reserves, but also went on the odd operational deployment. I've been staff on countless training courses, ranging from recruit courses, through to training Ares and ARA soldiers in all kinds of Green army and SF courses. My last deployment was being part of a team where we trained Coalition forces (U.S. and Iraqi) in various aspects of Counter Insurgency warfare.

There is a saying in the military:

"There is no such thing as a bad soldier. There are only bad trainers, NCO's and officers."

What that means is that a pilot in an airline is a product of his or her C&T system. There is NO REASON why a 300 hour pilot shouldn't be in the RHS of an ATR, Dash, 737 or A320. Provided that they are trained correctly.

This happens all around the world, particularly in places like Europe and Asia where there isn't a GA industry to supply large volumes of high time applicants.

If the training that a pilot receives at VARA focusses more on procedures, being "word perfect" in checklist responses, etc. rather than on FLYING THE AIRCRAFT you will continue to see incidents and accidents like this happen.

DV – “What that means is that a pilot in an airline is a product of his or her C&T system.”

This is not the place for an in depth look at the statement above, which is IMO 70% correct. Other underlying factors which demand analysis comprise the remaining 30%. Beginning with the ‘official’ dictates at flight school level where the basic building blocks of multi engine operations are taught – some of the tales from that field are truly scary. Then there is the tortured ‘approval’ process for a C&T system, which has produced some bizarre results, cast in stone and ‘black letter’ compliance. Then there is the HR element of pilot ‘selection’ which perpetuates and compounds the system flaws.

Back in the day – to convert a pilot to a new aircraft type, it was a matter of introducing the systems, peculiarity’s and ‘differences’ of the aircraft which would be added to the existing basic skills. In recent times as much time again and often more is needed to bring the basic flying skills to an acceptable level – before applying those skills to a new aircraft type.

DV – “There is NO REASON why a 300 hour pilot shouldn't be in the RHS of an ATR, Dash, 737 or A320. Provided that they are trained correctly.”

Agreed; and, provided both elements of the raw material are up to specification. – The small skills, like maintaining speed control all the way to the touch down point and the training skills to recognize a potential ‘hole’ in the knitting, before it becomes a tangle of machinery and tarmac.

Big topic, but Bravo Di Vosh for having the grit to even attempt to raise it. No good discussing it here though – just wasting wind - preaching to the converted.

The boss of Sydney Seaplanes has described the actions of a highly experienced pilot during New Year's Eve's deadly crash as "totally inexplicable".

Key points:
Six people died when the seaplane crashed on New Year's Eve
The ATSB has begun its investigation into the incident
Sydney Seaplanes has since resumed flights
The Australian Transport Safety Bureau today released an interim report into the crash, which killed six people north of Sydney last month.

The report has found the plane was still climbing out of the Cottage Bay area when it banked 80 to 90 degrees to the right before diving into 13-metre-deep waters killing pilot Gareth Morgan and five passengers onboard.

Sydney Planes chief executive Aaron Shaw said that was "inexplicable".

"The key question arising from the report is why the plane crashed, approximately halfway down Jerusalem Bay, which is surrounded by steep terrain and has no exit," he said.

"It is not a route we authorise in our Landing and Take-off Register and the plane simply should not have been where it was.

"Further, the aircraft is then reported to have entered into an 80 to 90 degree bank angle turn.

"A turn of this nature at low altitude by a pilot with Gareth's skill, experience and intimate knowledge of the location is totally inexplicable."

Pilot was 1km off course: report

The Sydney Seaplanes' standard flight path out of the Cottage Point area is to climb north into Jerusalem Bay before turning right towards Cowan Creek and into the body of the Hawkesbury River before high enough altitude is gained to fly over the surrounding bushland.

According to the report, the path Mr Morgan took was about 1 kilometre off that standard course.

Witnesses report that the plane flew to the left of Jerusalem Bay before taking an 80-90 degree turn and diving into the water.

Richard Cousins, 58, his two sons, Edward, 23, and William, 25, his 48-year-old fiancee Emma Bowden and her 11-year-old daughter Heather Bowden-Page, all from Britain, were killed in the crash.

Mr Cousins, who was chief executive of Compass Group, had recently been recognised by the Harvard Business Review for his work as chief executive of the multinational catering company.

Ms Bowden was the art editor at British publication OK! Magazine where she worked for 15 years.

The main body of the 55-year-old de Haviland DHC-2 Beaver, including the engine, the propeller, the floats and the tail, were recovered from Jerusalem Bay earlier this year.

All parts of the plane were taken to the Australian Transport Safety Bureau in Canberra for analysis.

Earlier it was revealed in a report from the ATSB that the craft was "destroyed" in a fatal accident 20 years ago.

The plane was once a crop duster that was involved in a serious crash near Armidale in November 1996, killing the pilot.

The boss of Sydney Seaplanes has described the actions of a highly experienced pilot during New Year's Eve's deadly crash as "totally inexplicable".

Key points:
Six people died when the seaplane crashed on New Year's Eve
The ATSB has begun its investigation into the incident
Sydney Seaplanes has since resumed flights
The Australian Transport Safety Bureau today released an interim report into the crash, which killed six people north of Sydney last month.

The report has found the plane was still climbing out of the Cottage Bay area when it banked 80 to 90 degrees to the right before diving into 13-metre-deep waters killing pilot Gareth Morgan and five passengers onboard.

Sydney Planes chief executive Aaron Shaw said that was "inexplicable".

"The key question arising from the report is why the plane crashed, approximately halfway down Jerusalem Bay, which is surrounded by steep terrain and has no exit," he said.

"It is not a route we authorise in our Landing and Take-off Register and the plane simply should not have been where it was.

"Further, the aircraft is then reported to have entered into an 80 to 90 degree bank angle turn.

"A turn of this nature at low altitude by a pilot with Gareth's skill, experience and intimate knowledge of the location is totally inexplicable."

Pilot was 1km off course: report

The Sydney Seaplanes' standard flight path out of the Cottage Point area is to climb north into Jerusalem Bay before turning right towards Cowan Creek and into the body of the Hawkesbury River before high enough altitude is gained to fly over the surrounding bushland.

According to the report, the path Mr Morgan took was about 1 kilometre off that standard course.

Witnesses report that the plane flew to the left of Jerusalem Bay before taking an 80-90 degree turn and diving into the water.

Richard Cousins, 58, his two sons, Edward, 23, and William, 25, his 48-year-old fiancee Emma Bowden and her 11-year-old daughter Heather Bowden-Page, all from Britain, were killed in the crash.

Mr Cousins, who was chief executive of Compass Group, had recently been recognised by the Harvard Business Review for his work as chief executive of the multinational catering company.

Ms Bowden was the art editor at British publication OK! Magazine where she worked for 15 years.

The main body of the 55-year-old de Haviland DHC-2 Beaver, including the engine, the propeller, the floats and the tail, were recovered from Jerusalem Bay earlier this year.

All parts of the plane were taken to the Australian Transport Safety Bureau in Canberra for analysis.

Earlier it was revealed in a report from the ATSB that the craft was "destroyed" in a fatal accident 20 years ago.

The plane was once a crop duster that was involved in a serious crash near Armidale in November 1996, killing the pilot.

On 31 December 2017, at about 1500[1] Eastern Daylight-saving Time,[2] the pilot and five passengers of a de Havilland Canada DHC-2 Beaver floatplane, registered VH-NOO and operated by Sydney Seaplanes, departed Cottage Point on a charter flight to Rose Bay, New South Wales.

The operator reported that the aircraft’s expected and standard flight path[3] after departing Cottage Point was to climb initially to the north then turn right along Cowan Creek toward the main body of the Hawkesbury River, until sufficient altitude was gained to fly above terrain and return to Rose Bay (Figure 1). While the exact take-off path from Cottage Point has yet to be established, the aircraft was observed by witnesses to enter Jerusalem Bay (Figure 1). The aircraft was observed to enter the bay at an altitude below the height of the surrounding terrain (Figure 2). Several witnesses also reported hearing the aircraft’s engine and stated that the sound was constant and appeared normal.

Shortly after entering Jerusalem Bay, numerous witnesses reported seeing the aircraft suddenly enter a steep[4] right turn and the aircraft’s nose suddenly drop before the aircraft collided with the water in a near vertical position. The aircraft came to rest inverted and with the cabin submerged. Witnesses reported the entire tail section and parts of both floats were initially above the waterline. The aircraft took over 10 minutes to completely submerge. A quantity of fuel was also observed in the water. A number of witnesses who heard or observed the impact responded to render assistance. All six occupants received fatal injuries.

The pilot held a current Commercial Pilot (Aeroplane) Licence that was last reissued by the Civil Aviation Safety Authority (CASA) on 21 March 2017 following a flight review and proficiency check. He also held a Republic of Maldives Airline Transport Pilot Licence. The pilot held a Class 1 Aviation Medical Certificate valid until 6 March 2018 and he was reported to have a high standard of health.

A copy of the pilot’s CASA licence provided by the operator indicated that he held single-engine and multi-engine aeroplane class ratings, and floatplane, manual propeller pitch control, and retractable undercarriage design feature endorsements.

The pilot’s last ratings (flight review and proficiency check) were issued on 11 March 2017. The ratings comprised a multi‑engine aircraft flight review and instrument proficiency check (valid until 31 March 2019 and 31 March 2018 respectively). The pilot’s logbook also indicated that he had completed a gas turbine engine design feature endorsement on 16 June 2017 and conducted a single-engine aircraft flight review on 29 June 2017 (valid until 30 June 2019). Information provided by the operator indicated that the pilot had a total flying experience of more than 10,000 hours, of which about 9,000 hours were on floatplanes.

The pilot had been employed by Sydney Seaplanes from 2011 to 2014 and then relocated overseas. On return to Australia in May 2017, the operator’s records indicated that the pilot had completed the following checks and training:

non-technical skills training in communication, situational awareness, decision making and workload management as part of the operator’s safety management system

fuel barge training

a C-208 compressor/turbine water wash course.

Aircraft information

The float-equipped DHC-2 Beaver is a predominately all-metal high-wing aircraft designed to carry one pilot and seven passengers. VH-NOO was manufactured in 1963 and first registered in Australia in 1964 (Figure 3). Viking Air (Canada) has been the type certificate holder since 2006. The aircraft was powered by a Pratt & Whitney ‘Wasp Junior’ R-985 nine‑cylinder, single‑row, air-cooled radial engine, which drove a Hartzell HC-B3R30-4B three‑blade propeller. The aircraft was operated in the charter category.

A periodic inspection of the aircraft was completed on 6 November 2017 and a new maintenance release was issued. A scheduled engine change was also carried out at this time. The installed engine had recently been inspected and test run by a maintenance organisation in the United States and had about 95 hours’ time-in-service at fitment.

The ATSB investigated a fatal accident involving the same aircraft, then configured for aerial agriculture operations including a fixed undercarriage, which occurred on 15 November 1996, resulting in the fatality of the sole occupant. The aircraft was subsequently repaired, issued with a Certificate of Airworthiness and re-entered service, registered as VH-NOO, in 2000. Sydney Seaplanes acquired the aircraft in 2006.

Environmental information

The nearest Bureau of Meteorology automatic weather station (AWS) was located at Terrey Hills, about 11 km south-south-east of Jerusalem Bay. Another AWS was located at Gosford about 22 km north-north-east of Jerusalem Bay. At 1500 on the day of the accident, the Terrey Hills AWS recorded the wind at 13 km/h (about 7 kt) from the north-east. The Gosford station recorded the wind at 20 km/h (about 11 kt) from the east-north-east. Witnesses positioned in Jerusalem Bay generally indicated that the wind was directly into the bay at various strengths,[5] which would have resulted in the aircraft experiencing a tailwind at the time the aircraft entered Jerusalem Bay.

The water depth at the wreckage location was 14.5 m. Bureau of Meteorology tidal recordings at the Ku-ring-gai Yacht Club (near Cottage Point), stated that it was low tide at 1400 indicating that the tide was in-coming at the time of the accident.

Wreckage recovery and examination

On 4 January 2018, the aircraft was recovered from the water, where it was established that both wings and floats had become separated from the fuselage (Figure 4). The aircraft was retrieved during three ‘secure and lift’ operations undertaken by the New South Wales Police Force Diving Unit and a barge operated crane crew. These were:

the main sections of both aircraft floats and the right wing

the main fuselage including the engine, propeller and tail section

the left wing.

The Police conducted further diving operations to retrieve the remaining aircraft debris and items on-board at the time of impact.

The aircraft was transported to secure facilities for further examination. Initial examination of the aircraft wreckage indicated:

all major sections of the aircraft structures were recovered

no evidence of a birdstrike or collision with an object prior to take-off or in-flight

no evidence of an in-flight break-up or pre-impact structural damage

the front of the aircraft and float tips had been significantly damaged

both the wings and floats had separated from the fuselage during the impact sequence

damage to wings was consistent with the aircraft being banked to the right at the time of impact

flight control continuity throughout, indicating no evidence of flight control issues[6]

the flaps were in the ‘climb’ position of 15 ± 1 degrees

there was no cockpit voice or flight data recorder (nor was there a regulatory requirement for an aircraft this size to be fitted with one)

there was no commercial video recording equipment fitted to the aircraft.

The engine, propeller and a number of aircraft components have been retained by the ATSB for further examination.

Figure 4: VH-NOO recovery from Jerusalem Bay
Source: ATSB

Fuel testing

Fuel samples were collected by the New South Wales Police Force from the operator’s refuelling point at Rose Bay. The fuel was tested by the ATSB for the presence of water, with nil indications found. A visual inspection did not identify any particle matter in the fuel. In addition, there were no reports of fuel quality concerns with the operator’s other DHC-2 aircraft utilising the same fuel source. The remainder of the fuel samples have been retained by the ATSB for further testing if required.

Sydney Seaplanes safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action taken by Sydney Seaplanes in response to this accident.

Immediately following the accident, Sydney Seaplanes suspended operations. They resumed operations in their C-208 amphibious aircraft on 15 January 2018, with an interim provision of having two crew on board.

The maintenance status of all aircraft has been reviewed, with all maintenance actions found to have been carried out as required.

Prior to commencing charter flights, all pilots will be re-checked in accordance with the operator’s proficiency standards. This will include additional low-level and stall training.

Ongoing investigation

The ATSB investigation is continuing and will include consideration of the following:

engine, propeller and aircraft component examinations

flight and engine control positions

aircraft maintenance history

obtaining and evaluating witness information

pilot qualifications, experience and medical information

impact sequence

survivability

aircraft performance and handling characteristics

aircraft weight and balance

operator policies and procedures

stall warning systems

nature of seaplane operations

environmental influences

sources of recorded information

similar occurrences in Australia and internationally.

The ATSB will continue to consult the engine and airframe type certificate holders, and utilise the expertise of the Seaplane Pilots Association of Australia. Accredited representatives from the Transportation Safety Board (TSB) of Canada and the United States National Transportation Safety Board (NTSB) have been appointed to participate in the investigation. A representative from the United Kingdom (UK) Air Accident Investigation Branch (AAIB) has been appointed as an expert to the investigation team under the same provisions. The AAIB will provide liaison with the passenger’s next-of-kin, citizen’s in the UK.

Acknowledgements

The ATSB acknowledges the support of the New South Wales (NSW) Police Force, Marine Area Command and Police Diving Unit; NSW Fire and Rescue, specialised operations and firefighting units from Metropolitan East 2; NSW National Parks and Wildlife Service; Sydney Metro Airports and those involved with the recovery of VH-NOO.

It is probably happening, but it would be nice if the media could add an extra appeal to anyone who has video footage of the take off to provide it to the NSW police or, even the ATSB. This is going to be a tough nut for the ATSB to crack, unless they find a clear cut answer during the investigation and 'video' may be a great help.

One of the habits beaten into a pilot's head, from day one, is to check the correct sense and function of all control surfaces before take off. A sea-plane take off involves much use of ‘rudder’ and elevator, but not too much in the way of aileron - in the low speed ranges. In trying to understand why the aircraft turned so far into Jerusalem Bay one of the possible theories discussed (speculation) is a control ‘lock-up’ or, partial failure of either the water rudder/ rudder or the aileron circuit. Please note - this is only idle speculation at the moment; and, as the ATSB will carefully examine the control circuits as part of their investigation, the discussion is only ‘one theory’ - related to the aileron control; a notion explored, if you will.

That said, you can easily find on You-Tube recorded demonstration of DHC 2 water take off. The sequence of events is routine and standard – the power is increased to the take-off setting as the speed increases to ‘rotate’ (take off speed) you will note a momentary, full aileron control input, to either the left or the right, followed by a return of the control to neutral. This is a deliberate action, to ‘unstick’ the float from the water surface, which allows the aircraft to become ‘airborne’. Had the aileron not returned to neutral, but ‘hung up’ and created an unscheduled left turn? Did this lead to a heavy right turn input (to prevent further penetration of Jerusalem Bay) which ‘unstuck’ the left aileron – suddenly and rapidly, producing a steep turn to the right?

No one knows at the moment, but there is a need to discover why an experienced pilot would enter that Bay. The flaw is ‘if’ there was a control problem, then why not just land straight ahead? To which the response is, if there was a control problem, he was safer ‘airborne’ than try to land on one float, without aileron control. So it goes, round and round the table; but, FWIW, that is the current, BRB best guess speculation.

Not quite O&O'd but nonetheless for what appears to be a fairly straight forward occurrence investigation one wonders what on earth was the delay...

Via the ATSB twitter minion today:

Quote:[email=ATSB‏@atsbinfo]ATSB[/email]‏@atsbinfo

ATSB report into the activation of a Bombardier DHC-8’s obstacle proximity warning. This report shows the importance of identifying the mode of auto-flight systems after an incorrect selection led to the aircraft descending too fast and too low. http://www.atsb.gov.au/publications/inve...-2015-045/

On 24 April 2015, a Bombardier DHC-8 aircraft, registered VH-TQM, was operating QantasLink flight QF2274 from Port Lincoln to Adelaide, South Australia.

During the approach to runway 30, in instrument meteorological conditions and with vertical navigation (VNAV) flight director mode engaged, the airspeed reduced. As the flight crew responded, an uncommanded disengagement of the aircraft’s flight director occurred. The flight crew re‑engaged the flight director and selected vertical speed mode. That mode resulted in the aircraft descending below the approach profile and 100 ft below a segment minimum safe altitude.

As the aircraft drew nearer to the runway, the flight crew received an obstacle proximity warning, since their projected approach path would bring them too close to a tower. In response, the crew conducted a missed approach and instead landed the aircraft on runway 05. No damage or injuries were sustained.

What the ATSB found

Flight director dropouts had occurred previously – including on that aircraft and on that day. On those occasions the flight director had automatically re-engaged in the same mode it had dropped out in. As the flight crew expected this would happen again, they continued the approach. The reason for the uncommanded disengagement of the aircraft's flight director was not established. The previous flight director dropouts had not been reported by company flight crew, affecting the operator's ability to resolve the issue and to educate flight crew about it.

The manual re-engagement of the flight director was done during a period of high workload and focus on other tasks and the flight crew did not identify the incorrect active mode. The captured vertical speed resulted in the aircraft descending too fast for the approach profile. Without the protection provided by VNAV mode, the aircraft descended below a segment minimum safe altitude. The altitude and vertical speed resulted in the activation of an obstacle proximity warning.

The elevation of the tower was incorrect on the published approach chart and in the terrain database, and there had been previous occurrences of obstacle warnings on that approach.

There were also deficiencies in the induction and route information provided to flight crew about the instrument approach.

What has been done as a result

Following this occurrence, QantasLink immediately prohibited use of the GNSS RWY 30 approach and has since undertaken a range of education, training and operational safety actions.

Airservices Australia amended the approach chart with the correct height of the tower. While safe obstacle clearance existed on the approach profile, they also amended the approach procedure to increase the clearance above the obstacle, with the aim of eliminating proximity alerts to aircraft on the approach profile.

Safety message

This incident highlights the importance of auto-flight system mode awareness and the adverse effects of flight crew expectation and high workload. It also demonstrates the value of operators conducting a thorough risk assessment and making flight crew aware of hazards associated with airport approaches.

Reporting of technical faults, even those that occur momentarily and resolve quickly, is important as it enables the operator to resolve the issue and educate flight crew.

P2 – “Not quite O&O'd but nonetheless for what appears to be a fairly straight forward occurrence investigation one wonders what on earth was the delay.”

Well, that’s fairly obvious; the subtext clearly defines the mad scramble to sort out the systemic errors – across the board. Alternatively the report was released early as some Muppet at ATSB thought Feb 1 was April 1.

Bit early for April 1 gags yet – ain’t it? This report is a joke surely, it must be. Some parts are absolutely hilarious, particularly the parts scribed by a person who’s first language ain’t English.

Of course the underlying ‘safety issues’ are not mentioned; which is very PC and extraordinarily PR, but no matter; I’m just glad they followed company SOP and had their Hi-Viz vests handy – real safety at work eh? Well done ASA though – how very decent of them to acknowledge and eventually correct a normalized deviance; so nice not to have to cancel an obstacle warning every time the approach is flown.

The good thing is this report has provided a perfectly valid reason to never, not ever, read another ATSB report – life is too short.

The wife of a pilot killed in last year's Essendon plane crash thanks the aviation community for its support on the anniversary of her husband's death, as an expert calls for a review of commercial development at airports following the tragedy that claimed five lives.

Pilot Max Quartermain's widow says her thoughts are with the families of everyone who died. (Credit: ABC)

The wife of a pilot killed in last year's Essendon plane crash has thanked the aviation community for its support on the anniversary of her husband's death, as an expert calls for a review of commercial development at airports.

Four American tourists and pilot Max Quartermain died when the Beechcraft King Air B200 aircraft clipped a building at the end of the runway in Melbourne's north, bursting into flames.

Workers at Essendon Fields will pause for a minute's silence at 9:00am today.

"At this time of immense sadness, my thoughts are with the families of everyone who died on the Beechcraft King Air flight 12 months ago," Mr Quartermain's widow Cilla Quartermain said in a statement.

Quote:"My only consolation during this period of grieving has been a strong belief that Max died doing what he loved the most and I know his greatest priority on the day as a pilot would have been the welfare of his passengers.

[size=undefined]"I would like to deeply thank all those who have provided support during the past year, from many people in the aviation industry, to many more I didn't know when they made contact."

Since the fatal crash, questions have been asked about the appropriateness of built-up commercial spaces and residential developments near airports.

Essendon Fields is home to the light aircraft airport as well as retail operations, including a 140-store factory outlet complex.
[/size]

Quote:"At this stage it's still quite a mystery as to why the aircraft was not able to maintain height and to continue to climb," aviation specialist Ron Bartsch of AvLaw Consulting said.

[size=undefined]"You can ask any pilot if they would prefer to attempt a forced landing on a grassed area or on a commercial development, I think the answer is pretty obvious.

"If you haven't got clear land around airports during the approach and departure phase then that obviously adds a hazard to the safety of air navigation.

"I think what's required is more detail and more comprehensive safety risk analysis ... of whether it's appropriate to have increased commercial developments on and near airports."

The approval process for this building was initially part of the Australian Transport and Safety Board's (ATSB) investigation, but has since been separated out.

"Due to the specialist nature of the approval process and airspace issues attached to the retail centre development — and to not delay the final report into the accident — the ATSB has decided to investigate this matter separately," an ATSB spokesman told the ABC.

The investigation is now complete and the final report is expected by the end of March.
The ATSB has not specified when the land development investigation will be completed.

Safety versus profit

Linfox and Beck Corporation signed a joint venture privatisation agreement with the Federal Government in 2001 to lease and operate the Essendon Airport and surrounding land.

The building of the retail centre on Bulla Rd, Essendon, was approved by the Federal Government in 2004.

Since then it has passed two certifications by the Civil Aviation Safety Authority (CASA).

"Every development which occurs on the airport involves CASA, Air Services (Australia) and the department (of Infrastructure and Regional Development) and goes through a very rigorous and extensive process," Essendon Fields CEO Chris Cowan said.

"Safety is at the forefront of everything we do at the airport and those processes are rigorous. They're applied across the world and we apply those here."

But aviation consultant Ron Bartsch said there was a potential conflict between the competing interests of the owners and operators.

"They're responsible for safety on the one hand as operators or the airports, [and] they're responsible for maximising on behalf of their shareholders.

"We can never ever compromise safety over commercial interests — detailed risk assessments of land use around airports will make sure that won't happen in the future."

John Washburn from Austin, Texas was one of four American friends flying from Essendon Airport to King Island to play golf on February 21st 2017 when their plane fell from the sky, hitting DFO Essendon and bursting in to flames.

She had joined her husband and three other couples from Texas on a "trip of a lifetime", heading to the Great Ocean Road with the women while the men played golf.

Yesterday, she shared a heartfelt letter to the Victorians who "took care of me during the most difficult few days of my life".

In the note — shared in full on the Herald Sun's website — Mrs Washburn said she was unsure about making a public statement on the anniversary of her husband's death but changed her mind "because I would like to say something to the people of Melbourne".

"While to be sure many of the emotions I’ve felt over the last year have not always been pleasant, the only emotion I have ever felt toward the people of Melbourne is gratitude."

She went on to share her thanks to those who laid flowers at the site of the accident.

She also expressed her gratitude to the staff of the Park Hyatt Melbourne ("particularly the bellman who asked if he could give me a hug") and those who held her hand at St Patrick's Cathedral in the days after the crash.

Her biggest acknowledgement went to Detective Inspector Stephen Cooper of the Victoria Police who, she said, spent "countless hours helping guide a grieving family through a horrible time — often at the expense of time with his own. Thank you, Coop.

You are a gentleman of the highest order, and I can never repay the debt".

[size=undefined]The Australian Transport Safety Bureau's preliminary report has ruled out engine failure. The final report is yet to be released. The crash remains Victoria's worst civil aviation incident in 30 years.[/size]

Not sure what IronBar's involvement is in all this but you can bet his ultimate motive will be something to do with money and some sort of dodgy deal or cover-up -

"Due to the specialist nature of the approval process and airspace issues attached to the retail centre development — and to not delay the final report into the accident — the ATSB has decided to investigate this matter separately," an ATSB spokesman told the ABC.

“BOLLOCKS” shouted the IOS team.

“The investigation is now complete and the final report is expected by the end of March.The ATSB has not specified when the land development investigation will be completed.”

“BOLLOCKS” shouted the IOS team.

"They're responsible for safety on the one hand as operators or the airports, [and] they're responsible for maximizing (what, exactly) on behalf of their shareholders.

“BOLLOCKS” shouted the IOS team.

In short, apart from a very genuine, heart felt statement from the widow; it’s all BOLLOCKS.

Rumour - “There was a runway excursion to the left, having entered from the right on a 45 metre wide runway in this class of aircraft is eyebrow raising in itself, (I wonder why this is a puzzle?) - there were at least two propeller strikes, (two runway lights down 60 metres apart), yet the takeoff was continued. Upon becoming airborne there was no attempt to fly the aircraft, the gear was not retracted, the engine was not shutdown and the propeller was not feathered. The pilot transmitted mayday for 5 of the 9 seconds of airborne time.”

Clearly – something went wrong, provided the above is totally ‘Kosher’. The fateful last precious seconds of the lives lost, each demand forensic, physical and educated examination. But; even so – the question, ‘was the building a hazard’ – demands investigation as part of the accident report. A separate, after the report investigation into buildings in ‘close’ proximity to active runways does deserves special attention. But ATSB cannot possibly, not in good conscience, ‘eliminate’ it from their report – not without a bloody good, believable explanation of ‘why’ it was not a factor – and why so many NOTAMS have been generated regarding the ‘runways’ at Essendon.